Integrated clinical pathways with watertight, multi-layer closure to improve patient outcomes in total hip and knee joint arthroplasty

Abstract

The number of primary total hip and knee replacement surgeries is increasing primarily due to an aging population. There is also a concomitant increase in the number of complications which could be attributed to high variation in arthroplasty techniques, peri-operative methods and the absence of integrated clinical pathways (ICP) to mitigate risks such as surgical site infections (SSIs). The implementation of ICPs incorporating watertight, multi-layer closure could increase the preventative effectiveness against joint prosthetic adverse events. The objective of this review is to describe the ICPs implemented by one US facility to help address ten adverse events synergistically.

Abbreviations

ACS

American College of Surgeons

AE

adverse event

CDC

Centers for Disease Prevention and Control

COE

Center of Excellence

EBM

evidence-based medicine

ERAS

enhanced recovery after orthopedic surgery

HAC

hospital acquired complication

HCUP

Healthcare Cost and Utilization Project

ICP

integrated clinical pathways

IHI

Institute for Healthcare Improvement

LOS

length of stay

MPSM

multimodal problem-solving methods

NIS

National Inpatient Sample

NSQIP

National Surgical Quality Improvement Program

PJI

peri-prosthetic joint infections

POUR

post-operative urinary retention

PONV

post-operative nausea and vomiting

PT

physical therapy

RTKA

revision total knee arthropathies

SIS

Surgical Infection Society

SSI

surgical site infections

THA

total hip arthroplasties

TKA

total knee arthroplasties

VTE

venous thromboembolism

WHO

World Health Organization

ZIOZ

Zero In on Zero program

1. Introduction

The number of primary total hip and knee replacement surgeries performed annually in the United States is increasing due in large part to an aging population, increasing rates of obesity^1,2 and pent up demand.³ There is also a concomitant increase in the number of complications, including surgical site infections (SSIs), blood transfusions, venous thromboembolism (VTE)-related re-admissions and deaths, poorly controlled and post-operative pain, post-operative urinary retention (POUR) and nausea and vomiting (PONV), early total hip dislocations, peri-prosthetic fractures and so on.⁴ Many of these adverse events may be attributed to high variation in arthroplasty techniques, peri-operative methods and the absence of integrated clinical pathways (ICP) to mitigate risks such as SSIs; including deep peri-prosthetic joint infections (PJIs).^5,6

Wound closure techniques in total hip arthroplasties (THA) or total knee arthroplasties (TKA) vary from traditional methods with interrupted deep sutures and surface staples to deep barbed sutures and surface closure choices that may include staples, adhesives, or subcuticular sutures. Innovative wound closure techniques along with multimodal problem solving can facilitate infection prevention. The implementation of ICPs incorporating advanced wound closure methods could increase the preventative effectiveness of a wide array of joint prosthetic adverse events.7, 8, 9

SSIs located in the incision, deep organ, or the associated deep procedural space are important targets of prevention efforts, and their public reporting is increasingly obligatory.¹⁰ SSIs occur in 2%–5% (160,000–300,000 annually in the US)¹¹ of patients who undergo inpatient surgeries, in general, and SSI including deep infections are the most common and costly of the healthcare-associated infections.12, 13, 14 For THA and TKA, US and International registry rates by 2015 varied from 0.76 to 1.24% for hips and 0.88 and 1.28% for knees; and they were higher than in the preceding 3 years.¹⁵ In 2011, primary total knee arthroplasty accounted for more than half of the 1.2 million prosthetic joint arthroplasty procedures (primary and revision) performed in the United States, followed by total hip arthroplasty and hip hemiarthroplasty.¹⁶ Furthermore, prosthetic joint arthroplasty procedures could increase to 3.48 million procedures annually by 2030.17, 18, 19 If the estimated rate of SSIs after primary total joint arthroplasty (0.2%–2.0%)²⁰ are correct, as derived from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, then SSIs could harm as many as to 7,600 to 76,000 total joint arthroplasty patients annually. Moreover, PJIs are among the most common reasons for total knee and total hip revision surgeries, for which the hospitalization costs average $25,692 and $31,753, respectively.²¹ Superficial infections represent the majority of these cases, followed by dehiscence and deep infections, respectively.²⁰ The cost of revision procedures was found in studies of the to have increased from $320 million to $560 million from 2001 to 2009, and was projected to reach $1.62 billion by 2020.²² From a societal perspective, significant and more preventable indirect costs may also result from patient disability and loss of wages and productivity.²³ Among the cases of SSI following total hip and knee arthroplasty, additional research from the NSQIP database found elevated mortality risk (3.7% vs. 0.1%) for those whose infections that worsened into sepsis.²⁴

The objective of this review is to describe the ICPs implemented by the Orthopedic Center of Excellence (COE) at TriHealth's Good Samaritan Hospital. Consistent ICP utilization greatly reduces ten significant adverse events including bleeding events requiring transfusion, SSIs, and VTE.⁶ The final stage in wound complication reduction is the multilayer closure technique preventing the flow of blood between layers and providing a biologic barrier to reduce the risk of SSI and providing cosmetic value to the patient.

2. Overview of an integrated clinical pathway (ICP)

2.1. Guidelines that address the prevention and reduction of SSIs

The World Health Organization (WHO) has shown that SSIs are common in 33% of patients who have undergone a surgical intervention and recently developed SSI prevention guidelines in 2016 which are supported by evidence-based recommendations applicable to the time periods before, during, and after surgery.²⁵ In the US, The Centers for Disease Prevention and Control (CDC) published a targeted systematic literature review in 2017 to address new and update SSI prevention recommendations that are meant to be incorporated into surgical practice to improve quality and safety.²⁶ Additionally, the American College of Surgeons (ACS) and the Surgical Infection Society (SIS) have published updated SSI prevention guidelines,²⁷ noting that important evidence exists to support the use of triclosan-coated sutures, based on clinical trials, systematic reviews and meta-analyses.

THAs and TKAs are among the important high volume and costly procedures targeted by quality improvement organizations such as the Institute for Healthcare Improvement (IHI) for SSIs.²⁸ Frequently, the treatment of SSIs will require re-hospitalization, additional surgery, and prolonged systemic antibiotic therapy. Following an SSI, a patient's mobility will be hampered, and they may require extended post-acute care rehabilitation. To avoid these consequences, IHI has published recommendations for key procedural changes in order to improve outcomes: using alcohol-containing antiseptic agents for preoperative skin preparation; instructing patients to bathe or shower with chlorhexidine gluconate soap for at least three days before surgery; screening patients for Staphylococcus aureus and decolonizing S. aureus carriers with five days of intranasal mupirocin; using appropriate prophylactic antibiotics; and appropriate hair removal. The challenge is that guidelines alone reduce the risk of but not necessarily the rate of surgical complications and adverse events (AEs).²⁹

2.2. Zero In on Zero (ZIOZ program)

A novel, multimodal problem-solving, Zero In on Zero (ZIOZ) program for total hip and knee replacement patients was developed to focus on reducing ten of the costliest and most debilitating potential AEs after lower joint replacement surgery.⁶ Components of ZIOZ include (1) evidence-based medicine (EBM), an approach to medical practice intended to optimize decision making by emphasizing the use of evidence from well-designed, highly regarded research; (2) ICPs, multidisciplinary care plans that detail essential steps in the care of patients with a specific clinical problem over the entire episode of care; and (3) multimodal problem-solving methods (MPSM), which involve utilizing structured problem-solving approaches to all major AEs at the same time through integrated implementation. Through the ZIOZ program, ICPs for ten sentinel AEs were initiated in 2011, including: allogenic blood transfusions, infected total hip and total knee arthropathies; prolonged length of stay (LOS), post-operative urinary retention (POUR) and post-operative nausea and vomiting (PONV) and delayed physical therapy (PT); all-cause 30-day readmission; poor discharge handoff; patient dissatisfaction; ineffective pain management; early primary total joint dislocation; in-hospital patient falls; 30-day readmission; readmission for VTE; and ineffective pain management (Appendix A).

The ZIOZ ICPs target the 120-day period before, during, and after total hip and knee surgeries. Resting on available and frequently updated evidence-based medicine design, the program involved stakeholders from multiple disciplines to help facilitate successful ICP enhancement of patient outcomes. The practices are built on several levels of evidence, as follows: strong evidence, including randomized clinical trials, Cochrane reviews, meta-analyses and clinical practice guidelines; moderate evidence, including retrospective reviews or variable amounts of evidence; and indeterminate evidence, where there may be only minimal or no supportive evidence.

The Orthopedics COE at TriHealth's GSH accomplished the near-eradication of SSIs via appropriate pre-, peri-, and post-operative infection prevention and clinical process optimization techniques throughout the continuum of care.

• •Pre-operatively: 30 days before surgery, patient activation needs to be integrated to mitigate risks. This includes smoking cessation, malnutrition recognition and correction, effective weight loss, narcotic cessation, sleep apnea diagnosis and treatment, and diabetic optimization. Moreover, anemia should be corrected to avoid unnecessary transfusions and 2% chlorhexidine preps used for pre-op skin cleansing.
• •Peri-operatively: Several steps are taken peri-operatively as part of the ICPs including 1) selecting products that decrease the risk of SSI; 2) avoiding excess operative time; 3) reducing or preventing wound drainage; 4) using 0.35% Betadine rinse or 0.05% 1–2 minute CHG rinse; 4) avoiding suture and staples for skin closure; and 5) significantly reducing total time under tourniquet to 5 minutes or less.
• •Post-operatively: The multi-layer watertight closure facilitates improved patient satisfaction within 90 days of surgery in addition to optimized pain management and expedited physical therapy. Narcotic minimization helps reduce the negative immune modulation effects of opioids when a full force multimodal medicine pain management system is used.³⁰

2.3. Wound closure by layer to ‘close the loop’ of ICP

Traditionally, many surgical procedures use staples and interrupted sutures that run continuously with knots or subcuticular sutures to ensure closure of large wound incisions, subcuticular incisions, and fascial repair. However, these methods may result in unpleasant cosmetic or functional outcomes for the patient, adding to patient dissatisfaction. Therefore, surgeons must be aware of alternative methods of wound closure that are not only cosmetically favorable, but also ensure rapid wound recovery and potentially better infection prevention.

For soft tissue approximation, we use the STRATAFIX™ Knotless Tissue Control Devices³¹ (Ethicon Inc., Somerville, NJ, USA) which currently has a portfolio of two technology: STRATAFIX™ Spiral and STRATAFIX™ SYMMETRIC.³² These devices eliminate the need to tie surgical knots and can reduce operating room time and potential knot-related complications.³³ Additionally, most of the STRATAFIX™ portfolio is treated with IRGACARE ® MP (triclosan) which inhibits bacterial colonization of the device as it does with traditional PDS™ Plus Suture.³⁴ A recent meta-analysis of 21 randomized controlled trials comparing triclosan-coated sutures with conventional sutures has shown a 28% reduction in the risk of SSI³⁵; however, such a result is yet to be confirmed in orthopedic application given that hip and knee arthroplasty is a clean surgery with relatively low baseline SSI rate which requires larger sample sizes to reach statistical significance.³⁶

The Dermabond™ Prineo™ Skin Closure System (Ethicon Inc., Somerville, NJ, USA) comprises two components: a self-adhering polyester mesh and 2-octylcyanoacrylate topical skin adhesive that creates a strong polymeric bond across wound edges.³⁷ This permits natural healing to occur, but with a synthetic flexible microbial barrier providing in vitro protection against organisms.

In order to achieve optimal multilayer, watertight closure following total knee replacement, the surgical team begins with suturing the fat pad with 2-0 running Vicryl. This is followed by closure of the joint capsule, using #1 PDS STRATAFIX™ Symmetric, and several #0 Ethibond interrupted sutures positioned around the medial patella femoral ligament. Subcutaneous closure is performed using bidirectional #1 PDO STRATAFIX™ Spiral. 2-0 PGA Spiral bidirectional STRATAFIX™ is used subcuticularly, followed by the self-adhering mesh of the Dermabond™ Prineo™ carefully applied to approximate the skin tissue and 2-octyl cyanoacrylate was used to coat gently on top of the adhesive mesh.

Following the total hip replacement procedure, the joint capsule is sutured using #0 Ethibond. The hip bursa is closed with #1 Spiral bidirectional STRATAFIX™. Then the iliotibial band is sutured using #1 PDS STRATAFIX™ Symmetric and several #0 Ethibond interrupted sutures. #1 Spiral PDO bidirectional STRATAFIX™ is used for subcutaneous closure, followed by 2-0 PGA Spiral bidirectional STRATAFIX™ for the subcuticular layer and the Dermabond™ Prineo™ Wound Closure System for skin closure.

3. Discussion and conclusions

Some of the current challenges in total joint arthroplasty practices include significant procedure-to-procedure and institution-to-institution inconsistency resulting in undermined pre-operative risk mitigation and highly variable operative time, multimodal problem solving (MMPS) efforts, VTE incidence, LOS, post-acute care costs, and 30- and 90-day readmission rates. The physician-led Orthopedic COE's ICP practices have facilitated the eradication of many common sentinel adverse events associated with lower extremity TJA which helped earn them 2013 and 2015 Joint Commission's Gold Seal of Approval for Total Hip and Knee and Advanced Certification status in 2017 reserved then for only 1% of US hospitals (Joint Commission).

The ability to reduce multiple hospital acquired complications (HAC) simultaneously in the pre-operative, intra-operative and post-operative setting has been the overarching goal of the ZIOZ-oriented TJA program. It is believed that when all AEs are addressed and mitigated in the same systematic way, all at the same time, the rates of all AEs are synergistically lowered.³⁸ The wound closure system involving the two products dovetails with ICP-driven success since, from the wound complication perspective, the combination of novel water-tight wound closure products and full functioning ICPs have the potential to eradicate more than 99% of the risk of surgical site complications. Consequently, the healthcare cost burden to the hospital and patients may be decreased if poor outcomes and readmission costs are radically managed.³⁹

Since the implementation of the ZIOZ program, more than 2,000 such surgeries have been performed at the primary hospital site, with no (zero) transfusions, no injurious hospital falls, no SSIs, no serious 90-day opioid complications, no early primary total hip dislocations, and fewer than 0.1% VTE related readmissions.³⁸ Combined all-cause 30- and 90-day readmission rates of less than 2% have also been observed. Additionally, full ZIOZ utilization has reduced the total per-episode cost of care for the institution by more than 20%, driven by shortened LOS and reduced readmissions and post-acute care minimization.³⁹ It is believed that when health care institutions closely adhere to the safety and quality recommendations that come out of this multimodal ICP program, they are more likely to enjoy a reduction in adverse events and better patient reported outcomes resulting from the ICPs. ICPs have been shown to provide a number of benefits to patients, including minimizing blood transfusions, peri-prosthetic infections and pain management issues, same-day and next-day LOS, in addition to leveraging enhanced recovery after orthopedic surgery (ERAS). For example, fewer transfusion events were experienced over time at TriHealth Good Samaritan Hospital from 2010 [monthly range 6.5–21.5%] to 2013 [0–2%] in 2013, when the monthly rate fell to below 0.5%. From 2012 through 2014, TKA/THA infection rates with ZIOZ compliance were lower than without compliance: 0.00–0.68% versus 1.00–1.28%, respectively. Additionally, THA and TKA falls with injury fell to a zero rate from June 2012 through December 2017.³⁸

3.1. SSI rates from literature

In a recent study of the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample of 235,857 revision total hip arthroplasties and 301,718 revision total knee arthropathies from 2005 to 2010, TKA (RTKA) procedures, the national average rates of SSI in total hip and knee arthropathies were reported at 2.0%–2.4%, respectively.²² A recent meta-analysis found that in 8 studies, 12 of 232 (5.2%) knees closed with sutures and 8 of 339 (2.4%) closed with staples had superficial post-operative infections. For deep infections in 8 studies, 3 of 294 (1.0%) cases receiving primary skin closures with sutures had deep infections versus 1 of 383 (0.3%) closures with staples.³⁹ Conversely, multivariable-adjusted rates of SSI diagnosis were 0.3%–0.5% among 1942 propensity-score-matched patients in a large US hospital database who received the Dermabond Prineo skin closure system or skin staples following total knee replacement.⁴⁰ However, due to limitations in the ability to accurately identify SSI in the hospital database, SSI was likely to have been under-estimated.

ICPs represent the evidence-based best practices to help address ten sentinel AEs synergistically in total joint arthroplasties and wound closure provide a key opportunity to address risk of surgical site infections within the ICP-enhanced total joint episode of care. Traditional wound closure techniques involving conventional suture, staples and wound dressings may not be the optimal choice to achieve the primary objective of multi-layer, watertight closure. The innovative combination of barbed suture coated with Triclosan together with a skin closure system comprising of a self-adhering mesh and 2-octyl cyanoacrylate, integrated within ICPs, may help achieve the desired reduction in complications and overall cost in the era of bundled payment for TJA.

4. CRediT roles statement

Mark A. Snyder: Conceptualization, Investigation, Methodology, Supervision, Validation, Visualization, Writing-review & editing. Alexandra N. Sympson: Conceptualization, Investigation, Project administration, Validation, Writing-review & editing. Steven J. Wurzelbacher: Conceptualization, Writing-review & editing. Po-Han Brian Chen: Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing-review & editing. Frank R. Ernst: Conceptualization, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing- original draft and review & editing.

Role of funding source

Funding provided by Ethicon, Inc., funded the development of the manuscript, and facilitated the coordination of the authors, gathering of information, and writing of the manuscript, as well participating in the decision to submit the article for publication.

Declaration of interests

Dr. Snyder has nothing to disclose. Mrs. Sympson has nothing to disclose. Mr. Wurzelbacher reports other from Ethicon/JnJ, outside the submitted work; and currently a consultant/faculty for Ethicon/JnJ. Dr. Ernst reports other from Ethicon/JnJ, during the conduct of the study; Mr. Chen has nothing to disclose.

The authors report competing interests from Ethicon/JnJ, outside the submitted work in the form of consultancies and employment.

APPENDIX A. ZIOZ Practices Associated with Before-, During-, and After-Surgery Phases of Care

ICP Target Adverse Event Type	Before THK Surgery	During THK Surgery	After THK Surgery
Blood Transfusions	Recognition of anemia with CBC more than 4 weeks prior to surgery (S)	Regional anesthesia (M)†	Avoidance of strong VTE chemoprophylaxis in low risk TKA patients (S)†
	Correction of Hgb <13 (males) and <12 (females) with erythropoietin and iron supplements (S)	Hypotensive anesthesia for those requiring general anesthesia	Lovenox 40 mg daily in TKA. INR targets near 1.5 for coumadin-treated patients (M)†
	Referral to hematology if Hgb < 10	Pre-op TXA given 15 mg/kg 15 minutes before incision (S)	Transfusion triggers 7/21 unless cardiac symptoms unstable (S)
	Avoidance of autologous donation (M)†	Decreased tourniquet time, bipolar cautery (W)†	IV fluid correction of hypotension and mild postural changes (I)
	–	Drain avoidance (M)†	–
Surgical Site Infection (SSI)	Weight-adjusted pre-operative antibiotics (S)	Avoid excessive operative times (M)†	Avoidance of strong VTE chemoprophylaxis in low risk TJA patients (M)†
	Correction of anemia to avoid transfusions (M)	Optimized OR environment: suits, staff and speech (M)†	Silver-eluting postoperative dressings (M)
	Optimizing health status (glycemic control, best BMI, smoking cessation, OSA treatment, malnutrition avoidance) and careful patient selection (S)†	Antibiotic-loaded bone cement in higher risk patients (M)†	Avoid blood transfusions, watch out for atrial fibrillation patients (S)
	Remote site infection and MRSA/MSSA eradication (S)†	0.5% 3 minute Betadine and chlorhexidine rinse and avoid skin staples (M)	Caregiver hand washing (S)†
	Chlorhexidine 2% skin cleansing (S)	Prevent wound drainage (S)†	Aggressive management of wound drainage (S)†
Orthopedic Acute Care Unit Falls	Recognition of “early faller” risk profile (M): delirium, history of falls, unsafe gait.	Regional anesthesia, MMPM, and reduction in narcotic meds (M)	Long-term commitment to exercise for strength, balance, function (M)
	Correction of strength deficits, imbalance, functional performance (M)†	Preference of Periarticular Injection over Femoral Nerve Blocks in TKA patients (S)	Elimination of narcotic, alcohol, anti-psychotic dependence (M)†
	Referral to Balance Clinic. Reduction/elimination of anti-psychotic meds (M)†	Attention to high risk periods: BR, unassisted, night shift (M)	Prolonged hospitalization for patients with functional deficits, residual nerve blocks (I)†
	Correction of vision deficits (I)†	Mentor, measure and market fall elimination goal in a systematic and systemic way throughout institution (M)	Effective discharge handoff to rehab destinations if poor home support (I)
30-Day Readmissions	Risk identification and mitigation with aggressive patient activation. RRAT, RAPT and AAHKS RAT utilization (S)†	Fully employ MPSM BPBs (S)†	Be sure SNF care process and home follow-up optimized in elderly patients (S)
	Plan to use MPSM protocols and celebrate with patient/family (S)†	Identify complications in process and reverse them (M)†	Use MMPM meds and VTE protocols to prevent falls and VTE readmissions (S)†
	Patient and family review of expectations and discharge plans (M)	Identify in-hospital medical (especially cardiopulmonary) and mental health unresolved issues prior to DC (M)	Since wound issues and prosthetic dislocation are surgical readmit factors, focus care and precautions accordingly (M)†
	In place rigorous SNF best practices protocols and communications (M)	Rapid mobilization and ERP protocol (M)	Complication reduction equals readmission reduction (S)
Poor Pain Management	Assess patient for pain catastrophizing (M) and narcotic use (M)†	Regional anesthesia (M) IV Dexamethasone DOS and POD 1 (S)†	Avoidance of strong VTE chemoprophylaxis in low risk TKA patients (S)†
	Pre-empt pain with regional analgesia (S)	Wound cocktail deep tissue injection safer than FNB (S) Bupivacaine DepoFoam suspension PAI (M)†	Continue multimodal meds (S)†
	Multimodal med initiation pre-op (S)	Decreased tourniquet time for ischemia minimization and DVT reduction (M)†	Reduce or eliminate singular reliance on narcotics to avoid narcotic SE (M)†
	Pharmacogenetic testing for medication optimization (I)†	Less invasive surgical approach (M)†	Link patient satisfaction with optimized pain control (M)†
Poor Discharge Handoff	Pre-op cues for patient > 65 years, high ASA class and functionally dependent (M).† RAPT tool (M). Alert to patient destination intentions.†	Interdisciplinary identification of barriers to discharge, realizing patient discharge destination expectation MOST influential (M)	Essential data elements in transition DC record are standardized. Inter-provider communication essential (S)
	PCP notified of admission plan and actual TJA schedule (M)†	Scheduled discharge meeting between DC planning RN, MD, patient and family – expectation agreement signed (M)†	Home and outpatient PT-based rehabilitation program for primary unilateral TKA/THA (S)
	Pharmacist/PCP or hospitalist collaboration on medication record (M)	Patient and family confirm that home DC with early outpatient PT not possible. Must match pre-op DC plans since so influenced by destination expectations. (M)†	Patient with higher ASA and/or CCI must be post discharge monitored for any level of care since readmit risk higher(S)
	Flagged preoperative discharge screening/patient selection of OCE endorsed SNF if need predicted (I)	Reinforce pre-op assurance that at home rehabilitation equally effective as in-patient rehabilitation (M)†	Post-acute care partnerships/networks optimize readmission risk reduction (M)
VTE Re-admissions/Deaths	Risk stratify: prior DVT, genetic risks, obesity, high CCI, COPD, depression, A Fib and anemia (S) VTEstimatorTM iOS (S)†	Regional anesthesia (M)†	ASA prophylaxis and SCDs in low risk patients is safer and more cost effective (S)†
	Bridge anticoagulants (LMWH) in anti-coagulated patients pre-op (M)	Tourniquet-less TKA technique (M)†	Consider variable dosing LMWH, Coumadin, Factor Xa inhibitor only in higher risk patients (M)†
	Avoid ABT by pre-op diagnosis and correction of anemia (S)	IV heparin during surgery for highest risk patients (I)†	Rapid, FWB mobilization (M)
	–	Avoid blood loss that could lead to ABT by using TXA (S)	Mobile SCDs add protective benefit (S)†
Prolonged LOS, PONV, POUR, Delayed PT/OT	Patient factors: Elderly patients (>75 years), ASA lll or lV, CV comorbidities, obesity, hypertension (S). POUR risk high if IPSS 8.†	Regional anesthesia and effective MMPM with PAI as found in ZIOZ (S)	Avoid PCA, excessive reliance on narcotics (M). Favor MMPM methods (S)†
	IV dexamethasone before induction to reduce PONV (M)	Tourniquet-less TKA technique in order to accelerate quad recovery and ambulation (M)†	Accelerated PT/OT with DOS start reduces LOS without adding readmission risk (M)
	Avoid ABT by pre-op diagnosis and correction of anemia (S)	IV Dexamethasone DOS and POD#1 to reduce PONV and improve pain control (S). Pre-empt POUR with Flomax	Home discharge plan versus SNF reduces LOS (M)
	Motivate patients/family to expect short LOS helped by DOS PT/OT and FWB with effective MMPM and little PONV or POUR (S)†	Avoid blood loss that could lead to ABT by using TXA, since ABT can extend LOS (S)	Prevent delirium (I)†
	Anticipate that hypertension and narcotics increase POUR/PONV (M)†	Nurse-driven bladder ultrasound check to reduce POUR risk (M)	–
Early THA Dislocation	Risk stratify: Age, female, TA, neuromuscular and cognitive disorders, patient noncompliance, soft tissue laxity, previous hip surgery (S)†	Regional anesthesia preference and narcotic reduced MMPM with PAI as found in ZIOZ (S)†	MMPM with narcotic reduction. Cognitive status determination prior to discharge (S)†
	Pre-op plan THA with optimal head size and surgical approach (M)†	Direct anterior or lateral approach (M) Posterior approach with capsule repair (S)†	Diminish precautions in most patients except for high risk group (M)
	Arrange for dual mobility cup in highest risk patients (M)†	Send to PACU and floor with abduction pillow or knee immobilizer (M)†	Rapid, FWB mobilization (S)
	Share registry-based complication and readmission rates that so that patient and family can freely choose (S)†	Target acetabular cup positions 45° or less for abduction and 15–20° anteversion but watch out for pelvic tilt (M)†	Revise after recurrent dislocation especially if malposition or abductor deficiency or high risk patient (S)†
Patient Dissatisfaction	Risk identify: pre-op pain catastrophizing, other site pain, low SF-36 mental health score, socioeconomic and patient demographic factors, less severe degenerative changes (S)†	Regional anesthesia and MMPM with strong pain pre-emption (S)†	Enhanced recovery and return to independent ADLs (S)†
	Change surgeons pre-op if patient dissatisfied with ipsilateral arthroplasty (M)†	Prevent THA leg length discrepancy, neurovascular injury and dislocation (S)†	Avoid weak therapy experience after TKA (M)†
	Younger age, females, severe pre-op symptoms, expectation of no pain post-op after TKA are at risk (S)	Expedited discharge and avoidance of pLOS using best practices like ZIOZ (S)†	Minimize residual symptoms and dysfunctions (S)
	High pre-op patient activation (patient engagement in adaptive health behaviors) improves outcomes and satisfaction (S)†	Meet post-op expectations and avoid complications -ZIOZ relevance (S)	Maximize symptom improvement, PRO scores (like PROMIS, KOOS & HOOS) and Quality of Life (S)†
	Transparency over quality of outcomes, safety, cost (use ZIOZ). Encourage patients with largely predictable and durable outcomes and QOL benefits (S)	Compassionate patient and family-centered care (S)†	Compassionate patient and family-centered care (S)†

^†Surgeon preference; otherwise, Integrated.

ICP, Integrated clinical pathway; THK, Total hip or knee surgery; ZIOZ, Zero in on Zero program; LOS, Length of stay; PONV, Post-operative nausea and vomiting; POUR, Post-operative urinary retention; PT/OT, Physical therapy/Occupational therapy; TKA, Total knee arthroplasty; THA, Total hip arthroplasty; (S), Strong evidence; (M), Moderate evidence; (I), Inconclusive evidence; CBC, Complete blood count; VTE, Venous thromboembolism; TXA, Tranexamic acid; Hgb, Hemoglobin; INR, International normalized ratio; IV, IntravenousTJA, Total joint arthroplasty; OR, Operating room; BMI, Body mass index; OSA, Obstructive sleep apnea; MRSA, Methicillin resistant Staphylococcus aureus; MSSA, Methicillin susceptible resistant Staphylococcus aureus; MMPM, Multimodal pain management; BR, Bathroom; RRAT, Rapid response assessment team; RAPT, Rapid assessment for psychopharmacologic treatment; AAHKS, American Association of Hip and Knee Surgeons; MPSM, Multimodal problem solving method; BPBs, Best practice bundle; DOS, Day of surgery; POD, Post-operative day; FNB, Femoral nerve block; PAI, Peri-articular injection; SE, Side effect; ASA, American Society of Anesthesiologists, or Aspirin [prophylaxis]; RN, Registered nurse; MD, Medical doctor; DC, Discharge; PCP, Primary care physician; CCI, Charlson Comorbidity Index; OCE, Outpatient code editor; SNF, Skilled nursing facility; COPD, Chronic obstructive pulmonary disorder; A.Fib, Atrial fibrillation; SCD, Sequential compression device; LMWH, Low molecular weight heparin; ABT, Allogeneic blood transfusion; FWB, Full weight bearing; CV, Cardiovascular; PACU, Post anesthesia care unit; ADLs, Activities of daily living; PRO, Patient-reported outcomes; PROMIS, Patient-Reported Outcomes Measurement Information System; KOOS, Knee injury and Osteoarthritis Outcome Score; HOOS, Hip disability and Osteoarthritis Outcome Score; QOL, Quality of life.

Appendix B. Supplementary data

The following is the supplementary data related to this article: